Aging populations and chronic illnessAging populations and the escalating prevalence of chronic lifelong diseases, will drive demand for healthcare in 2015, and impose significant burdens on healthcare systems.

Europe has the world’s highest proportion of people over 60. By 2017, 20% of Europeans will be over 65. By 2050 about 40% will be over 60. The US has similar trends. This aging and the increasing prevalence of chronic lifestyle diseases will continue to drive healthcare expansion, and pressure to reduce healthcare costs.

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Gordon MooreProfessor, Harvard University Medical School and world renowned authority on the design and implementation of healthcare delivery systems

'Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer, connect the participants up in real time, and create smart, real-time process support.'

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Curing the Problems of General Practice

The Royal College of General Practice (RCGP) and the Centre for Workforce Intelligence (CFWI) agree: too small a supply of GPs will meet a rising tide of demand. In the UK, spotty shortages exist now, but will become widespread over the next decade.

Little analysis of root causes Less is known about the underlying causes of the shortfall of supply in GPs. The RCGP cites lagging GP incomes as a source of dissatisfaction, with consequent dampening effects on medical student choices of general practice specialist careers. The CFWI models GP supply, but offers little analysis of the root causes of the declining intake to GP careers.

While both the RCGP and the CFWI repeatedly emphasize the need to make general practice more attractive and increase its uptake, they have few suggestions about how to do so other than promoting it better. In the meantime, they advocate, as does the NHS, that larger, multi-skilled teams must grow to service the increasing need, and that the key barrier to effective teamwork is lack of integration.

Concerns I want to raise two significant policy concerns about the direction that the UK is taking to mitigate the primary care “crisis”. First, I postulate that the reason that medical students are not choosing general practice is less a matter of money than of increasing practice complexity and life style. Second, I suggest that the “solution” of larger, better-integrated teams is unproven and, further, may actually diminish productivity, and worsen, rather than relieve, the stress of work on GPs while their satisfactions further diminish.

Lifestyle challenges There is little evidence that medical students will select GP careers if they earned more. In fact, over the past five years, during the rapid upturn in GP incomes, dissatisfaction among GPs grew and fewer medical students, especially men, chose to enter general practice. In the US, studies have shown that life style is an important factor in the diminishing number of medical students entering primary care. At the same time, corporate primary care is growing, and larger practices with more salaried doctors are becoming the work choice of preference.

This suggests that young doctors are put-off by the complexity, responsibility, the long hours, and the stress of general practice, and seek to transfer those risks to someone else. Without fixing this, throwing more money at the problem is unlikely to reverse the trend. Money, of course, is important, but it’s merely an enabler of career choice and a deterrent if too low. Compensation alone doesn't appear to be a sufficient incentive to chose primary care.

Multi-purpose teams failing The idea is seductive that integrated, multl-manpower teams are a solution to the GP shortfall. However, early evidence from America doesn’t suggest that the US-version of integrated, primary care teams (the patient-centered medical home) is achieving the efficiencies and improved care that they were touted to deliver. Recent studies (see: Friedberg M.W., 26th February 2014, Journal of the American Medical Association) show some small improvements in quality measures, but no change in cost-effectiveness in a group of enthusiastic early adopters.

There are many reasons to doubt that simple team integration occurs by encouraging it among those working together, and much to suggest that the cost of integration is a major barrier to a cost-effective strategy to increase manpower. Information technology, as a field, discovered years ago that taking complex tasks and dividing them among many different subgroups was dis-economic.

Additional manpower not the answer As long ago as 1975, Frederick Brooks in The Mythical Man-Month argued convincingly that by, “adding manpower to a late project makes it later”. No surprise then that when one counts the cost of personnel, the coordination mismatches, the communication time, the complexity of handoffs, and duplication of services, teamwork is more a theoretical concept than a practical working model.

Adopt best practice What, then, might one consider as a possible solution to the increasing stress, complexity, and uncertainty of life as a GP? What is needed to facilitate integration among and between team members and patients? Surely, we can draw lessons from other industries. Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer (think of Cash Points), connect the participants up in real time, and create smart, real-time process support.

The role of technology Digital infrastructure for general practice has failed to keep up with the rest of the world. The electronic medical record documents what has been done but does little to help doctors and other health workers to do their work. There is no infrastructure to help patients. Information technology should be providing an infrastructure to make general practice easier and better to do.

Merely throwing non-GP manpower at their problems will make the life of the GP more complicated and less satisfying. It is time to invest in true infrastructure innovation in the NHS. It won’t be cheap, but it is the only answer to the threat that general practice will fail to meet the needs of the population in future.

'We must tap into the largest unused source of manpower: the patients themselves.'

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Meeting the challenges of affordable quality healthcare

Health care systems throughout the world are about to be hit by a tsunami. Dramatically escalating GP demand is driven by the growth of life-style-related chronic illness, the surge of baby-boomers, a primary-care doctor shortage in some countries, and, in America, the surge of unmet needs now paid for by Obamacare. Either the current system will seize up, or new ways of caring for patients must be found.

Healthcare systems must find a way to reduce the costs as they struggle to meet this surge of demand. The old manpower-based responses, which at first seem attractive solutions, are unsustainable in the long run.

4 musts What are the answers?

First, we must tap into the largest unused source of manpower: the patients themselves. Anyone who cares for patients with diabetes, smoking, or high blood pressure knows that the best plans of GPs often are not carried out despite many repeated visits to the doctor or nurse.

Second, to activate patients, care support for them must be truly patient-centred. Patients need help to gain confidence necessary to take control of their own therapeutic pathways. Such a system of support requires “having your doctor in your pocket”, which should be entertaining, engaging, educational, available 24/7, continuously helpful, personalized, and safe.

Third, “having your doctor in your pocket,” can only be achieved if IT is used in new and innovative ways. The most cost-effective avenue by which we can move patients with chronic illnesses to become more actively involved in their own care is through the Internet, where dramatic shifts in user interfaces, devices, and process interactions are taking place almost daily. By transferring expert knowledge to patients and thereby creating a truly patient-centred system, caring for ones’ own illness will be no more difficult than using a cash machine or mastering a smart phone.

Finally, if the Internet can facilitate the transfer of knowledge from the medical system to the patient, then also it can facilitate the transfer of expert health knowledge to lower the cost of all clinical personnel from doctors to nurses to health coaches. If guidelines, such as those produced by NICE in the UK, are built into the process of care that health professionals use, we would have developed a system that significantly extends the capacity of health professionals while maintaining the safety and quality aspects of care that increasingly people expect and demand. An apt analogy is the way that today’s cockpit technology enables all pilots to be as good as the best. Through the use of technology, we can do the same in medical care.

The past is no indication of the future Today, healthcare is largely using IT to reproduce what doctors have done in the past. The electronic record is little different to paper records. In the evolution of any new technology, its application development goes through this stage. However, we must put IT to use in doing new things, in innovation that reduces our dependence on expensive manpower and in producing more value for less money.

Making such a transition will not be easy or inexpensive. But the costs of remaining the same and trying to meet escalating healthcare demands by adding more costly inputs are higher and more threatening in the long run. We should be investing in the future, not tinkering with the present.